• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
 Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
 

Diagnosis and Treatment of Obstructive Sleep Apnea in Adults

on

  • 1,932 views

Diagnosis and Treatment of Obstructive Sleep Apnea in Adults

Diagnosis and Treatment of Obstructive Sleep Apnea in Adults

Statistics

Views

Total Views
1,932
Views on SlideShare
1,927
Embed Views
5

Actions

Likes
0
Downloads
0
Comments
0

1 Embed 5

http://parksmedicallegal.blogspot.com 5

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Title Slide: Diagnosis and Treatment of Obstructive Sleep Apnea in Adults This slide set is based on a comparative effectiveness review (CER) titled Diagnosis and Treatment of Obstructive Sleep Apnea in Adults, which was developed by Tufts Evidence-based Practice Center, Tufts Medical Center, Boston, MA for the Agency for Healthcare Research and Quality (AHRQ) under Contract No. 290-2007-10055-I and is available online at www.effectivehealthcare.ahrq.gov/apena.cfm. CERs are comprehensive systematic reviews of the literature that usually compare two or more types of treatment with usual care for the same disease. For this CER, the existing body of evidence on the relative benefits and possible harms of different interventions used to diagnose and treat obstructive sleep apnea (OSA) were reviewed. The literature included in this review was identified in searches for trials and studies that included terms for OSA, sleep apnea diagnostic tests, sleep apnea treatments, and relevant research designs. Only studies on adults (≥16 years of age) were included. Searches were conducted for studies published through September 2010. It should be noted that this report does not discuss other types of sleep apneas, such as central or mixed sleep apnea.
  • Outline of Material The material in this presentation covers the results and conclusions from a systematic comparative effectiveness review entitled Diagnosis and Treatment of Obstructive Sleep Apnea in Adults . It begins with an introduction to obstructive sleep apnea, how it is diagnosed, and the available treatment options. It also covers: methods used to plan and execute the systematic review, clinically important questions the review sought to answer, results of the review, evidence-based conclusions about effectiveness and harms of diagnostic and treatment interventions, gaps in knowledge, as well as future research needs uncovered by the systematic review. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Background: Characteristics of Obstructive Sleep Apnea Individuals with obstructive sleep apnea (OSA) experience repeated airway collapse and obstruction during sleep, resulting in partial or complete cessation of airflow (hypopnea or apnea, respectively), oxygen desaturation, and arousals from sleep. The frequency with which hypopnea and apnea occur varies, however, they may happen as often as once each minute. Airway obstruction results in repeated cycles of loud snoring, disruption of rapid eye movement (REM) sleep, and frequent arousals throughout the night. Typical symptoms of OSA include poor sleep quality, excessive sleeping, and daytime sleepiness, although many patients may be asymptomatic. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm Victor LD. Obstructive sleep apnea. Am Fam Physician 1999;60:2279-86. PMID: 10593319. http://www.ncbi.nlm.nih.gov/pubmed/10593319
  • Background: Epidemiology of Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is a common disorder that affects people of all age is most prevalent among the middle-aged and the elderly. The prevalence of OSA appears to be high (10%-20%) and seems to be increasing, possibly in association with increasing rates of obesity. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm Young T, Shahar E, Nieto FJ, et al. Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Arch Intern Med 2002;162:893-900. PMID: 11966340. http://www.ncbi.nlm.nih.gov/pubmed/11966340
  • Background: Adverse Clinical Outcomes Associated With Obstructive Sleep Apnea Due to its associated morbidity and mortality rates, attendant comorbidities, and adverse effects on quality of life, obstructive sleep apnea (OSA) is an important public health issue of considerable clinical concern due. The wake-time effects of OSA are serious enough to affect concentration at work and while driving. Indeed, individuals who experience OSA are more likely to be involved in motor vehicle and other types of accidents. OSA has been associated with a variety of adverse clinical outcomes, such as cardiovascular disease (cardiac disease, stroke, and hypertension); noninsulin dependent diabetes and other metabolic abnormalities; and surgical complications. Studies show that before diagnosis, patients with OSA have increased rates of health care use, more frequent and longer hospital stays, and greater health care costs than after diagnosis. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm Victor LD. Obstructive sleep apnea. Am Fam Physician 1999;60:2279-86. PMID: 10593319. http://www.ncbi.nlm.nih.gov/pubmed/10593319 Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 2008;5:136-43. PMID: 18250205. http://www.ncbi.nlm.nih.gov/pubmed/18250205. Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000;283:1829-36. PMID: 10770144. http://www.ncbi.nlm.nih.gov/pubmed/10770144 Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J, and the Cooperative Group Burgos-Santander. The association between sleep apnea and the risk of traffic accidents. N Engl J Med 1999;340:847-51. PMID: 10080847. http://www.ncbi.nlm.nih.gov/pubmed/10080847 Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5. PMID: 8464434. http://www.ncbi.nlm.nih.gov/pubmed/8464434
  • Background: Diagnosis of Obstructive Sleep Apnea (1 of 3) In order to definitively determine whether a patient has obstructive sleep apnea, he or she must participate in a sleep study in a sleep laboratory or other setting. The American Sleep Disorders Association has classified the different monitors used in sleep studies into four categories based on the type of information each collects and the data synthesis mechanism utilized. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Background: Diagnosis of Obstructive Sleep Apnea ((2 of 3) Polysomnography (PSG), classified as type I sleep monitoring, is the current diagnostic standard for obstructive sleep apnea (OSA). PSG involves an overnight sleep-laboratory study during which neurophysiologic and cardiorespiratory signals are recorded. Sleep studies incorporate a number of assessments and measurements, including recordings of rapid eye movements, electroenchephalogram to detect arousals, chest and abdominal wall monitors to evaluate respiratory movements, electrocardiogram, electromyogram, oximetry, and nasal and oral air flow measurements. Portable sleep monitors (types II, III, and IV sleep monitoring) can and are being used in hospitals, sleep centers, or at-home settings to reduce resource requirements and to obtain results more representative of a typical night’s sleep. Various questionnaires and clinical prediction rules have also been used to assist in decreasing the resources required for diagnosis. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm Polysomnography Task Force of the American Sleep Disorders Association Standards of Practice Committee. Practice parameters for the indications for polysomnography and related procedures. Sleep 1997;20:406-22. PMID: 9302725. http://www.ncbi.nlm.nih.gov/pubmed/9302725
  • Background: Diagnosis of Obstructive Sleep Apnea (3 of 3) The severity of obstructive sleep apnea (OSA) is typically quantified by the number of apneas and hypopneas per hour of sleep measured during overnight monitoring. This measurement is called the apnea-hypopnea index (AHI). AHI, when combined with determinants of obstruction, is the primary measurement for the diagnosis of OSA. To define OSA, the American Academy of Sleep Medicine uses a threshold of 15 events per hour (with our without OSA symptoms) or 5 events per hour with OSA symptoms (unintentional sleep episodes during wakefulness; daytime sleepiness; unrefreshing sleep; fatigue; insomnia; waking up breath-holding, gasping, or choking; or the bed partner describing loud snoring, breathing interruptions, or both during patient’s sleep). The minimum thresholds to diagnose sleep apnea reported in research studies vary from 5 to 20 events per hour, measured by polysomnography. Individuals with frequent events (an AHI greater ≥ 30 events per hour) are more likely to be at risk for adverse outcomes. There is no established threshold level for AHI that indicates the need for treatment. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm American Academy of Sleep Medicine. The International Classification of Sleep Disorders: diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005. Epstein LJ, Kristo D, Strollo PJ Jr, et al, for the Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5:263-76. PMID: 19960649. http://www.ncbi.nlm.nih.gov/pubmed/19960649
  • Background: Treatment of Obstructive Sleep Apnea (1 of 2) Obstructive sleep apnea (OSA) is commonly treated with continuous positive airway pressure (CPAP), but many patients refuse to use CPAP therapy, do not tolerate it, or fail to use it properly. There are various types of CPAP that allow for choices regarding fit, air pressure, humidity, and oral versus nasal. Oral devices can also be used to treat OSA, most commonly mandibular advancement devices (MADs). MADs are generally fitted by a dentist and come in various designs to allow for choices about the degree of mandibular advancement, adjustment options, material, fit, tongue stabilization, and intraoral versus extraoral placement. The American Academy of Sleep Medicine recommends oral appliances for patients with mild to moderate OSA who prefer the oral appliance to CPAP, do not respond to CPAP, cannot have CPAP for various reasons, or who fail CPAP. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Background: Treatment of Obstructive Sleep Apnea (2 of 2) Surgical options may be used alone or in combination, depending on the patient’s anatomy and tolerance for surgery and the surgeon’s discretion. Because obesity is an underlying cause of obstructive sleep apnea for many patients, weight loss can be an effective definitive treatment. Other treatment options available are positional therapy and alarms, oropharyngeal exercises, nasal dilator strips, atrial overdrive pacing, acupuncture and auricular plaster therapy, and drug therapies (ventilatory stimulants or REM sleep suppressants). Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Background: Challenges to Diagnosis and Treatment Diagnosis and treatment of obstructive sleep apnea (OSA) are complicated by: inconsistent definitions of OSA; debate concerning the level of respiratory abnormality that defines the disorder; and a lack of consensus on the most appropriate diagnostic approach. Patient compliance is also often a barrier to effective treatment. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm Trikalinos TA, Ip S, Raman G, et al. Home Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome. Technology Assessment (Prepared by Tufts–New England Medical Center Evidence-based Practice Center). Rockville, MD: Agency for Healthcare Research and Quality; August 2007. Available at: www.cms.gov/determinationprocess/downloads/id48TA.pdf . Accessed July 7, 2011. Parthasarathy S, Haynes PL, Budhiraja R, et al. A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine Accreditation on management of obstructive sleep apnea. J Clin Sleep Med 2006;2:133-42. PMID: 17557485. http://www.ncbi.nlm.nih.gov/pubmed/17557485
  • Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others. A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. The results of these reviews are summarized into clinician guides and consumer guides for use in decisionmaking and in discussions with patients. The guides and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov.
  • Clinical Questions Addressed by the CER (1 of 2) In preparing the report on which this continuing medical education (CME) activity is based, the authors aimed to answer seven Key Questions. Key Questions 1–3 are listed below: KQ1. How do different available tests compare in their ability to diagnose obstructive sleep apnea (OSA) in adults with symptoms suggestive of disordered sleep? How do these tests compare in different subgroups of patients, based on: race, gender, body mass index (BMI), existing non-insulin dependent diabetes mellitus, existing cardiovascular disease, existing hypertension, clinical symptoms, previous stroke, or airway characteristics? KQ2. How does phased testing (screening tests or battery followed by full test) compare to full testing alone? KQ3. What is the effect of preoperative screening for OSA on surgical outcomes? Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Clinical Questions Addressed by the CER (2 of 2) In preparing the report on which this CME activity is based, the authors aimed to answer seven Key Questions. Key Questions 4–7 are listed below: KQ4. In adults being screened for obstructive sleep apnea (OSA), what are the relationships between apnea-hypopnea index (AHI) or oxygen desaturation index, and other patient characteristics with long term clinical and functional outcomes? KQ5. What is the comparative effect of different treatments for OSA in adults? KQ6. In OSA patients prescribed nonsurgical treatments, what are the associations of pretreatment patient-level characteristics with treatment compliance? KQ7. What is the effect of interventions to improve compliance with device use (positive airway pressure, oral appliances, positional therapy) on clinical and intermediate outcomes? Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Rating the Strength of Evidence From the CER Throughout this slide set, strength of evidence ratings are assigned to findings of the report . Strength of evidence is typically assigned to reviews of medical treatments after assessing four domains: risk of bias, consistency, directness, and precision. Although these categories were developed for assessing the strength of treatment studies, the domains apply also to studies of prevalence and screening. Available evidence for each Key Question was assessed for each of these four domains; the domains were combined qualitatively to develop the strength of evidence for each Key Question. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Effectiveness of Portable Devices and Polysomnography There is a low strength of evidence that Type II monitors are accurate to diagnose obstructive sleep apnea (as defined by polysomnography) and a moderate strength of evidence for Type III and IV monitors. However, the monitors have a wide and variable bias in estimating the actual AHI. The evidence is insufficient to adequately compare specific monitors to each other. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Effectiveness of Questionnaires and Clinical Prediction Rules There is a low strength of evidence that the Berlin Questionnaire is moderately accurate (has high sensitivity and specificity) to screen for obstructive sleep apnea (OSA). The strength of evidence is insufficient to evaluate other questionnaires, but one study found that STOP-Bang a questionnaire may have high enough sensitivity to accurately screen for OSA. The strength of evidence is also insufficient to determine the utility of phased testing or preoperative sleep apnea screening. There is a low strength of evidence that some clinical prediction rules (a morphometric model and a pulmonary function data model) may be useful in the prediction of a diagnosis of OSA, but these tools have not been validated externally. Nine clinical prediction rules have been used for the prediction of a diagnosis of OSA (using different criteria). The oropharyngeal morphometric model gave near perfect discrimination (area under the curve [AUC] = 0.996) to predict the diagnosis of OSA, and the pulmonary function data model had 100 percent sensitivity with 84 percent specificity to predict diagnosis of OSA. The remaining models reported diagnostic lower sensitivities and specificities. a. STOP-Bang = Snoring, Tiredness during daytime, Observed apnea, and high blood Pressure plus body mass index, age, neck circumference, and gender variables. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Effectiveness of Phased Testing and Preoperative Screening The evidence did not permit an estimation of the utility of phased testing followed by full testing (when indicated) to diagnose sleep apnea. Only one study that met the inclusion criteria addressed this question. This prospective study did not fully analyze phased testing and not all participants received full testing by polysomnography (PSG). The evidence also did not permit an estimation of the effectiveness of mandatory screening for OSA with respect to postoperative outcomes. Two prospective studies assessed the effect of preoperative screening for sleep apnea on surgical outcomes. One study of patients undergoing bariatric surgery found no significant differences in outcomes between patients who had mandatory PSG or PSG based on clinical parameters. A second study of general surgery patients found that perioperative complications were more likely to occur among patients willing to undergo preoperative PSG, possibly suggesting that patients willing to undergo PSG are more ill than other patients. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Correlation of AHI with Health Outcomes There is a high strength of evidence that an apnea-hypopnea index (AHI) ≥ 30 events per hour (HR, 1.5-3.0) is an independent predictor of all-cause mortality, although one study found that this was true only in men under the age of 70 years. There is a low strength of evidence that a higher AHI (AHI ≥ 8 events per hour, in one study; Botros, 2009) is associated with incident diabetes (OR, 2.81-4.06), though possibly confounded by obesity, which may result in both OSA and diabetes. The strength of evidence is insufficient to determine the association between AHI and other clinical outcomes. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm Botros N, Concato J, Mohsenin V, et al. Obstructive sleep apnea as a risk factor for type 2 diabetes. Am J Med 2009;122:1122-7. PMID: 19958890. http://www.ncbi.nlm.nih.gov/pubmed/19958890 Reichmuth KJ, Austin D, Skatrud JB, et al. Association of sleep apnea and type II diabetes: a population-based study. Am J Respir Crit Care Med 2005;172:1590-5. PMID: 16192452. http://www.ncbi.nlm.nih.gov/pubmed/16192452
  • Comparative Effectiveness of Continuous Positive Airway Pressure Machines Versus Mandibular Advancement Devices There is a moderate strength of evidence that continuous positive airway pressure (CPAP) and mandibular advancement devices (MAD) are effective treatments for obstructive sleep apnea and improve sleepiness and lower apnea-hypopnea index (AHI) values when compared to control treatments or no treatment. There is also a moderate strength of evidence that CPAP is superior to MAD in achieving an AHI of ≤ 5 events per hour. However, there is insufficient evidence to determine which patients might benefit most from treatment with CPAP, MAD, or CPAP compared to MAD. Note that studies of MAD predominantly exclude patients with comorbidities or unsafe levels of sleepiness. It is also important to note that current research evaluates only intermediate outcomes, and thus these findings may not apply to long-term clinical outcomes. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Meta-analysis of Apnea-hypopnea Index in Randomized Controlled Trials of MAD Versus CPAP Overall, nine trials provided data on apnea-hypopnea index (AHI) outcomes; all trials reported that AHI was lower among patients on continuous positive airway pressure (CPAP) than among those using mandibular advancement devices (MAD). The results were statistically significant in seven of the trials. Meta-analysis of the nine trials with adequate data found that the difference in AHI between MAD and CPAP was statistically significant, favoring CPAP (difference = 7.7 events per hour; 95 percent CI = 5.3, 10.1; P <0.001). Analysis of the net difference assessed in the two parallel trials and of the difference of final values in the six crossover trials yielded similar findings. However, the trial results were statistically heterogeneous due to the different devices being tested. References: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm Lam B, Sam K, Mok WY, et al. Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea. Thorax 2007;62:354-9. PMID: 17121868. http://www.ncbi.nlm.nih.gov/pubmed/17121868 Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 2004;170:656-64. PMID: 15201136. http://www.ncbi.nlm.nih.gov/pubmed/ 15201136 Clark GT, Blumenfeld I, Yoffe N, et al. A crossover study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest 1996;109:1477-83. PMID: 8769497. http://www.ncbi.nlm.nih.gov/pubmed/8769497 Ferguson KA, Ono T, Lowe AA, et al. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest 1996;109:1269-75. PMID: 8625679. http://www.ncbi.nlm.nih.gov/pubmed/8625679 Gagnadoux F, Fleury B, Vielle B, et al. Titrated mandibular advancement versus positive airway pressure for sleep apnoea. Eur Respir J 2009;34:914-920. PMID: 19324954. http://www.ncbi.nlm.nih.gov/pubmed/19324954 Randerath WJ, Heise M, Hinz R, et al. An individually adjustable oral appliance vs continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Chest 2002;122:569-75. PPMID: 12171833. http://www.ncbi.nlm.nih.gov/pubmed/12171833 Tan YK, L'Estrange PR, Luo YM, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial. Eur J Orthod 2002;24:239-49. PMID: 12143088. http://www.ncbi.nlm.nih.gov/pubmed/12143088 Hoekema A, Stegenga B, Wijkstra PJ, et al. Obstructive sleep apnea therapy. J Dent Res 2008;87:882-7. PMID: 18719218. http://www.ncbi.nlm.nih.gov/pubmed/18719218. Hoekema A, Stel AL, Stegenga B, et al. Sexual function and obstructive sleep apnea-hypopnea: a randomized clinical trial evaluating the effects of oral-appliance and continuous positive airway pressure therapy. J Sex Med 2007;4(4 Pt 2):1153-62. PMID: 17081222. http://www.ncbi.nlm.nih.gov/pubmed/17081222 Skinner MA, Kingshott RN, Jones DR, et al. Lack of efficacy for a cervicomandibular support collar in the management of obstructive sleep apnea. Chest 2004;125:118-26. PMID: 14718430. http://www.ncbi.nlm.nih.gov/pubmed/14718430
  • Comparative Effectiveness of Continuous Positive Airway Pressure Machines Autotitrated continuous positive airway pressure (autoCPAP) is a CPAP device that automatically adjusts the level of delivered pressure based on the patient’s requirements. There is moderate strength of evidence that autoCPAP and fixed continuous positive airway pressure (CPAP) result in similar compliance and treatment effects for patients with obstructive sleep apnea (OSA). There is low strength of evidence that there is no substantial difference in compliance or other outcomes between flexible CPAP (adjusts air pressure to accommodate exhalation) and CPAP. The strength of evidence is insufficient regarding comparisons of different CPAP devices or modifications, such as oral CPAP, nasal CPAP, bilateral positive airway pressure (PAP), flexible bilateral PAP, and humidified CPAP or autoCPAP. It is important to note that current research evaluates only intermediate outcomes, and thus these findings may not apply to long-term clinical outcomes. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Effectiveness of Surgical Interventions There are different types of upper airway surgeries as well as bariatric surgery that could be done to treat obstructive sleep apnea (OSA). However, studies on surgical interventions are limited, and the strength of evidence is insufficient to evaluate their effectiveness when compared to sham surgery, no treatment, or other OSA interventions like continuous positive airway pressure or mandibular advancement devices. It is important to note that current research evaluates only intermediate outcomes, and thus these findings may not apply to long-term clinical outcomes. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Other Outcomes of Interest (1 of 2) There is a low strength of evidence that some intensive weight-loss programs could be effective treatment for obstructive sleep apnea (OSA) in obese patients. There is also insufficient evidence to compare the effectiveness of other potential treatments for OSA, such as drugs, palatal implants, oropharyngeal exercises, tongue-retaining devices, positional alarms, bariatric surgery, nasal dilator strips, acupuncture, and auricular plaster. There is a moderate strength of evidence that more severe OSA, as measured by higher apnea-hypopnea index score, is associated with greater compliance with CPAP use. The ESS is a short questionnaire that is the standard measure of scoring daytime sleepiness symptoms. There is also a moderate strength of evidence that higher scores on the Epworth sleepiness scale (ESS) are also associated with improved CPAP compliance. The strength of evidence is insufficient regarding potential predictors of compliance with mandibular advancement devices. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Other Outcomes of Interest (2 of 2) There is a low strength of evidence that some intensive weight-loss programs could be effective treatment for obstructive sleep apnea (OSA) in obese patients. There is also insufficient evidence to compare the effectiveness of other potential treatments for OSA, such as drugs, palatal implants, oropharyngeal exercises, tongue-retaining devices, positional alarms, bariatric surgery, nasal dilator strips, acupuncture, and auricular plaster. There is a moderate strength of evidence that more severe OSA, as measured by higher apnea-hypopnea index score, is associated with greater compliance with CPAP use. The ESS is a short questionnaire that is the standard measure of scoring daytime sleepiness symptoms. There is also a moderate strength of evidence that higher scores on the Epworth sleepiness scale (ESS) are also associated with improved CPAP compliance. The strength of evidence is insufficient regarding potential predictors of compliance with mandibular advancement devices. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Adverse Events: Continuous Positive Airway Pressure Treatment with continuous positive airway may result in one or more of the following adverse events: claustrophobia, nasal and oral dryness (including nosebleeds), pressure discomfort, gum or lip soreness or pain, excessive salivation, skin irritation, nasal irritation and obstruction, aerophagia, abdominal distension, and chest wall discomfort. The adverse events listed here are evaluated based on cohorts of patients who received specific treatments within each randomized controlled trial, rather than by intertrial comparisons. Furthermore, many studies included short-term outcomes and provided little evidence regarding long-term adverse events. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Adverse Events: Mandibular Advancement Devices Mandibular advancement devices are associated with the following adverse events: sleep disruption, sensations of pressure in the mouth, mucosal erosions, excessive salivation, dental crown damage, loosening of teeth, and tooth, mouth and jaw pain/damage. Note that adverse-event reporting in the evaluated studies was sparse. The adverse events listed here are evaluated based on cohorts of patients who received specific treatments within each randomized controlled trial, rather than by intertrial comparisons. Furthermore, many studies included short-term outcomes and provided little evidence regarding long-term adverse events. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Adverse Events: Surgery and Weight Loss Postsurgical complications after obstructive sleep apnea (OSA) surgical interventions can include infection, hemorrhage, nerve palsies, emergency surgical treatments, cardiovascular events, respiratory failure, rehospitalization, and death. Long-term adverse events resulting from OSA surgical interventions can include speech or voice changes, difficulties swallowing, and airway stenosis. There were no reported long-term adverse events associated with weight-loss programs. Note that adverse-event reporting in the evaluated studies was sparse. The adverse events listed here are evaluated based on cohorts of patients who received specific treatments within each randomized controlled trial, rather than by intertrial comparisons. Furthermore, many studies included short-term outcomes and provided little evidence regarding long-term adverse events. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Conclusions (1 of 2) A high apnea-hypopnea index (AHI) is associated with all-cause mortality and diabetes, providing evidence for the importance of identifying such individuals. Portable monitors can predict a diagnosis of obstructive sleep apnea (OSA), but additional studies are needed to prove their value compared with polysomnography. Some questionnaires may be useful screening tools. Continuous positive airway pressure remains the most effective treatment for OSA, but mandibular advancement devices also improve sleepiness and reduce AHI. In patients who are obese, weight-loss programs show promise as an effective treatment. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Conclusions (2 of 2) There is insufficient evidence to evaluate the effectiveness of surgery and other treatment options. Compliance remains a barrier to treatment with continuous positive airway pressure, but there is insufficient evidence to evaluate compliance with other treatment options. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • Knowledge Gaps and Future Research Needs Current studies have not adequately evaluated long-term clinical outcomes. The effectiveness of treatment is based on intermediate measures such as sleepiness and apnea-hypopnea index. However, trial evidence is lacking to determine whether improving sleep-study measures has any affect on mortality or comorbities. There is insufficient clinical trial evidence to evaluate the effectiveness of many obstructive sleep apnea (OSA) treatments, including surgery. However, it is difficult to interpret surgical studies, because patients being considered for surgery are often not comparable to those being considered for nonsurgical treatments. Among seven clinical trials, four found surgery to be an effective treatment for OSA (vs. no treatment), but three found no improvement in OSA measures or outcomes. Studies evaluating surgery versus other treatment options were similarly heterogeneous. No studies use subgroup analysis in evaluating the effectiveness of treatments. Patient adherence is a major problem inhibiting the effectiveness of continuous positive airway pressure treatment, but the relative compliance rates with mandibular advancement devices or other treatment interventions have not been evaluated. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm
  • What To Discuss With Your Patients and Their Caregivers Things you should discuss with your patients and their caregivers regarding obstructive sleep apnea (OSA) and its detection and treatment include: The serious negative health outcomes associated with OSA. Evidence is lacking for many long-term outcomes; however, intermediate outcomes such as sleepiness and the number of episodes of apnea and hypopnea can be improved. The diagnostic and screening tools available to test for and evaluate OSA status and severity. The potential benefits and adverse events associated with CPAP, MAD, and other treatment options – including the importance of compliance. Patient preferences regarding diagnosis and treatment. Reference: Balk EM, Moorthy D, Obadan NO, et al. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32 (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality; July 2011. AHRQ Publication No. 11-EHC052-EF. http://www.effectivehealthcare.ahrq.gov/apnea.cfm

 Diagnosis and Treatment of Obstructive Sleep Apnea in Adults Diagnosis and Treatment of Obstructive Sleep Apnea in Adults Presentation Transcript

  • Diagnosis and Treatment of Obstructive Sleep Apnea in Adults Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov
  • Outline of Material Introduction to obstructive sleep apnea (OSA), diagnosis, and treatment. Systematic review methods. The clinical questions addressed by the comparative effectiveness review. Results of studies and evidence based conclusions about the effectiveness and harms of OSA diagnosis and treatment. Gaps in knowledge and future research needs. What to discuss with patients and their caregivers.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Background: Characteristics of Obstructive Sleep Apnea Obstructive sleep apnea (OSA) involves repeated upper airway collapse during sleep. This results in partial or complete cessation of breathing (hypopnea or apnea, respectively). The frequency with which cessation of breathing occurs varies, but it can happen more than once each minute. OSA symptoms include poor sleep quality, excessive sleeping, and daytime sleepiness. Many people with OSA are asymptomatic.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.Victor LD. Am Fam Physician 1999;60:2279-86. PMID: 10593319.
  • Background: Epidemiology of Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is relatively common in the United States. It is most prevalent among the middle-aged and elderly, although it affects people of all ages. The prevalence of OSA appears to be high and has been reported to be 10%–20% among middle-aged and older adults. The prevalence of OSA among those aged 65 years and older is believed to be higher.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.Young T, Shahar E, Nieto FJ, et al. Arch Intern Med 2002;162:893-900. PMID: 11966340.
  • Background: Adverse Clinical Outcomes Associated With Obstructive Sleep Apnea  Increased risk for cardiovascular disease.  Cardiac disease.  Hypertension.  Stroke.  Increased risk for noninsulin dependent diabetes and other metabolic abnormalities.  Increased likelihood of motor vehicle and other accidents due to daytime sleepiness.  Increased risk for perioperative and postoperative complications.  Decreased quality of life.  Decreased concentration.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011. Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.Victor LD. Am Fam Physician 1999;60:2279-86. PMID: 10593319; Punjabi NM. Proc Am Thorac Soc 2008;5:136-143. PMID: 18250205; Nieto FJ, Young TB, Lind BK,et al. JAMA 2000;283:1829-1836. PMID: 10770144; Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J, and the Cooperative Group Burgos-Santander.N Engl J Med 1999;340:847-51. PMID: 10080847; Young T, Palta M, Dempsey J, et al. N Engl J Med 1993;328:1230-5. PMID: 8464434.
  • Background: Diagnosis of Obstructive Sleep Apnea (1 of 3)Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Background: Diagnosis of Obstructive Sleep Apnea (2 of 3) Polysomnography (PSG) is the current diagnostic standard for obstructive sleep apnea. Portable sleep monitors can be used in a hospital, home setting, or sleep unit. Questionnaires and clinical prediction rules are also used in diagnosis and for case finding.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.Polysomnography Task Force of the American Sleep Disorders Association Standards of Practice Committee. Sleep 1997;20:406-22. PMID: 9302725.
  • Background: Diagnosis of Obstructive Sleep Apnea (3 of 3) The apnea-hypopnea index (AHI) is used as a metric to diagnose obstructive sleep apnea (OSA) and to classify disease severity.  AHI = The number of apnea and hypopnea events per hour of sleep. There is no current AHI threshold that indicates the need for treatment. By consensus, individuals with few episodes of disordered breathing (often AHI <5 or <15 events per hour) are not formally diagnosed with OSA. Individuals with frequent events (AHI ≥30 events/hr) are more likely to be at risk for adverse outcomes.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.American Academy of Sleep Medicine. The International Classification of Sleep Disorders: diagnostic and coding manual. 2nd ed. 2005.Epstein LJ, Kristo D, Strollo PJ Jr. et al, for the Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine.J Clin Sleep Med 2009;5:263-76. PMID: 19960649.
  • Background: Treatment of Obstructive Sleep Apnea (1 of 2) Continuous positive airway pressure machine Oral devices, most commonly mandibular advancement device Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011. Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Background: Treatment of Obstructive Sleep Apnea (2 of 2)  Surgery  Weight loss  Positional therapy  Oropharyngeal exercises  Nasal dilator strips  Atrial overdrive pacing  Acupuncture  Auricular plaster therapy  Drug therapies – ventilator stimulation, REM sleep suppression Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011. Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Background: Challenges to Diagnosis and Treatment The definition of obstructive sleep apnea (OSA) is inconsistent. There is debate about the level of respiratory abnormality that defines the disorder. There is also debate about the most appropriate approach to diagnose OSA. Patient compliance is often a barrier to effective treatment.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.Trikalinos TA, Ip S, Raman G, et al. Home Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome. August 2007.Available at: http://www.cms.gov/determinationprocess/downloads/id48TA.pdf.Parthasarathy S, Haynes PL, Budhiraja R, et al. J Clin Sleep Med 2006;2:133-42. PMID: 17557485.
  • Agency for Healthcare Research and Quality (AHRQ)Comparative Effectiveness Review (CER) Development Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others.  A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment.  The results of these reviews are summarized into Clinician Guides and Consumer Guides for use in decisionmaking and in discussions with patients. The Guides and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov.
  • Clinical Questions Addressed by the CER (1 of 2) Key Question (KQ) 1: How do different available tests compare in their ability to diagnose OSA in adults with symptoms suggestive of disordered sleep? How do these tests compare in different subgroups of patients, based on: race, gender, body mass index (BMI), existing non- insulin dependent diabetes mellitus, existing cardiovascular disease, existing hypertension, clinical symptoms, previous stroke, or airway characteristics? KQ2: How does phased testing (screening tests or battery followed by full test) compare to full testing alone? KQ3: What is the effect of preoperative screening for OSA on surgical outcomes?Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Clinical Questions Addressed by the CER (2 of 2) Key Question (KQ) 4: In adults being screened for obstructive sleep apnea (OSA), what are the relationships between apnea- hypopnea index (AHI) or oxygen desaturation index, and other patient characteristics with long term clinical and functional outcomes? KQ5: What is the comparative effect of different treatments for OSA in adults? KQ6: In OSA patients prescribed nonsurgical treatments, what are the associations of pretreatment patient-level characteristics with treatment compliance? KQ7: What is the effect of interventions to improve compliance with device use (positive airway pressure, oral appliances, positional therapy) on clinical and intermediate outcomes?Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Rating the Strength of Evidence From the CER The strength of evidence was classified into four broad categories: Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011. Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Effectiveness of Portable Devices andPolysomnography At-home monitors accurately predict elevated AHI suggestive of obstructive sleep apnea (OSA) (but cannot accurately estimate exact AHI values as measured by sleep-laboratory polysomnography):  Type II monitors. Strength of evidence: low  Type III and IV monitors. Strength of evidence: moderate There is insufficient evidence to compare the different at-home monitors.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Effectiveness of Questionnaires and ClinicalPrediction Rules The Berlin Questionnaire has high sensitivity and specificity in screening for obstructive sleep apnea (OSA). Strength of evidence: low There is insufficient evidence to evaluate:  The commonly used STOP and STOP-Bang questionnaires.  The effectiveness of most questionnaires in screening for OSA. Strength of evidence: insufficient Some clinical prediction rules (a morphometric model and a pulmonary function data model) may have predictive capacity, but these tools have not been validated externally. Strength of evidence: lowBalk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Effectiveness of Phased Testing and PreoperativeScreening There is insufficient evidence to evaluate the effectiveness of phased testing for detection of obstructive sleep apnea (OSA). Strength of evidence: insufficient There is insufficient evidence to evaluate postoperative outcomes after mandatory preoperative screening for OSA. Strength of evidence: insufficientBalk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Correlation of AHI with Health Outcomes Severe obstructive sleep apnea (OSA) (AHI ≥30 events/hr) is a predictor of all-cause mortality (HR, 1.5–3.0). Strength of evidence: high A high baseline AHI is correlated with diabetes (OR, 2.8–4.1). Strength of evidence: low The strength of evidence is insufficient regarding the association between AHI and other clinical outcomes. Strength of evidence: insufficientAHI: apnea-hypopnea index; HR: hazard ratio; OR: odds ratio.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.Botros N, Concato J, Mohsenin V, et al. Am J Med 2009;122:1122-7. PMID: 19958890.Reichmuth KJ, Austin D, Skatrud JB, et al. Am J Respir Crit Care Med 2005;172:1590-5. PMID: 16192452.
  • Comparative Effectiveness of CPAP vs. MAD CPAP and MAD improve sleepiness and lower AHI values when compared to control treatments or no treatment. Strength of evidence: moderate CPAP is superior to MAD in achieving an AHI of ≤5 events per hour. Strength of evidence: moderate Evidence is insufficient to address which patients might benefit most from treatment with CPAP, MAD, or CPAP compared to MAD. Strength of evidence: insufficient CPAP = continuous positive airway pressure machine; MAD = mandibular advancement device. Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011. Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Meta-analysis of Apnea-hypopnea Index in RCTs of MAD Versus CPAPBalk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Comparative Effectiveness of ContinuousPositive Airway Pressure Machines Autotitrated continuous positive airway pressure machines (CPAP) and fixed CPAP are equally effective. Strength of evidence: moderate Trials evaluating flexible CPAP (C-Flex) showed no statistically significant differences in compliance or other outcomes versus CPAP. Strength of evidence: low Evidence is insufficient to compare other CPAP devices (oral CPAP, nasal CPAP, bilateral PAP, flexible bilateral PAP, and humidified CPAP or autoCPAP). Strength of evidence: insufficient*Current research evaluates only intermediate outcomes, so these findingsmay not apply to long-term clinical outcomes.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Effectiveness of Surgical Interventions The studies for surgical interventions are limited, and current evidence is insufficient to determine their effectiveness when compared to sham, no treatment, or other obstructive sleep apnea (OSA) interventions. Strength of evidence: insufficientBalk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Other Outcomes of Interest (1 of 2) Weight-loss programs may be an effective treatment for OSA (vs. control interventions) in patients who are obese. Strength of evidence: low There is insufficient evidence to compare the effectiveness of other treatments for OSA, such as drugs, implants, exercises, positional approaches, acupuncture, and nasal dilator strips. Strength of evidence: insufficientBalk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Other Outcomes of Interest (2 of 2) Compliance with OSA treatments:  High apnea-hypopnea index and Epworth sleepiness scale are predictors of improved CPAP compliance. Strength of evidence: moderate  Evidence is insufficient to evaluate potential predictors of mandibular advancement device compliance. Strength of evidence: insufficient  Some specific adjunct interventions may improve CPAP compliance, but studies are heterogeneous and no general type of intervention (e.g., education, telemonitoring) was more promising than others. Strength of evidence: lowBalk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Adverse Events: Continuous PositiveAirway Pressure Continuous positive airway pressure may be associated with the following adverse events:  claustrophobia,  nasal and oral dryness (including nosebleeds),  pressure discomfort,  gum or lip soreness or pain,  excessive salivation,  skin irritation,  nasal irritation and obstruction,  aerophagia,  abdominal distension, and  chest wall discomfort.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Adverse Events: MandibularAdvancement Devices Mandibular advancement devices may be associated with the following adverse events:  sleep disruption,  sensations of pressure in the mouth,  mucosal erosions,  excessive salivation,  dental crown damage,  loosening of teeth, and  tooth, mouth, and jaw pain/damage.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Adverse Events: Surgery and Weight Loss Surgery  Postsurgical complications  Infection, hemorrhage, nerve palsies, emergency surgical treatments, cardiovascular events, respiratory failure, rehospitalization, and death.  Long-term adverse events  Speech or voice changes, difficulty swallowing, and airway stenosis. Weight-loss programs  No reported long-term adverse events.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Conclusions (1 of 2) A high apnea-hypopnea index (AHI) is associated with all-cause mortality and diabetes, so it is important to identify individuals with obstructive sleep apnea (OSA). Portable monitors can predict a diagnosis of OSA, but additional studies are needed to prove their value compared with polysomnography. Some questionnaires may be useful screening tools. Continuous positive airway pressure remains the most effective treatment for OSA. Mandibular advancement devices also improve sleepiness and reduce AHI. In obese patients, weight-loss programs show promise as an effective treatment.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Conclusions (2 of 2) There is insufficient evidence to evaluate the effectiveness of other treatment options, including surgery. Compliance remains a barrier to continuous positive airway pressure treatment, but there is insufficient evidence to evaluate compliance with other treatment options.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • Knowledge Gaps andFuture Research Needs Current studies have not adequately evaluated long-term clinical outcomes. There is insufficient clinical trial evidence to evaluate the effectiveness of many obstructive sleep apnea (OSA) treatments, including surgery. No studies use subgroup analysis in evaluating the effectiveness of treatment. Patient adherence is a major problem inhibiting the effectiveness of CPAP treatment, but the relative compliance rates with MAD or other treatment interventions have not been evaluated.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.
  • What To Discuss With Your Patientsand Their Caregivers The serious negative health outcomes associated with obstructive sleep apnea (OSA). Evidence is lacking for many long-term outcomes; however, intermediate outcomes such as sleepiness and the number of episodes of apnea and hypopnea can be improved. The diagnostic and screening tools available to test for and evaluate OSA status and severity. The potential benefits and adverse events associated with CPAP, MAD, and other treatment options – including the importance of compliance. Patient preferences regarding diagnosis and treatment.Balk EM, Moorthy D, Obadan NO, et al. AHRQ Comparative Effectiveness Review No. 32. July 2011.Available at: http://www.effectivehealthcare.ahrq.gov/apnea.cfm.